Tuesday, August 12, 2014

How I can accommodate a contracture of the fifth digit only?

Continuing our work with Restorative Medical, Inc., below we share a question from an Orthotic Fitter to Karen Bonn of Restorative Medical, Inc. and the best response:

Question: Do you have a recommendation as to how I can accommodate a contracture of basically the fifth digit only? Therapist also wants to treat ulnar drift and "max pain" in bilateral hands.  The picture is below.

Response: I would suggest a prefabricated Prosperity Hand™ (if you cannot do Custom Hand Splints), and mold the 3rd/4th finger plate down with a heat gun to apply only mild, comfortable stretch.  As the finger’s range improves, that plate can be gradually remolded to continue the PROCESS toward full extension.

If the Ulnar Drift is at the wrist, order the Ulnar Drift Strapping or at the very least the Velcro® on wrist pad. Correcting these deformities will help relieve the discomfort.

If it is from the MCPs and effects the fingers only, we would normally recommend the Ulnar Drift Finger Separators, and add the Ulnar Drift Strapping if needed. 

Since the Prosperity Hand™ is recommended for this patient, it might create a challenge to use finger separators since the base under the fingers is split between the 3rd and 4th digits. We can make a Velcro®-on pad the correct size to fit on the lateral side of the little finger to help correct the Ulnar Drift.  The finger strap that separates the 3rd finger from the 4th should adequately correct any Ulnar Drift in the 1st and 2nd fingers. Ulnar Drift tends to be a very painful condition so – as any lost range of motion condition – we want to provide a gradual comfortable stretch.

Please let this patient’s clinicians know it takes 6 weeks of prolonged low load passive stretch to realign the proteins (Actin and Myosin in the Sarcomere "units") in the muscle to PREPARE the muscle to be relengthened (not restretched).  It is so common for people to look at all patients as if they were orthopedic patients and perform aggressive stretching for a length of time, and then assume that is all that can be done when they do not achieve good results.  Instead, if they adjust the correct technology of splint to only put comfortable, flexible low load passive stretch on the joint(s), then keep them on caseload just until the therapist is comfortable with the wearing schedule, the splint is adjusted to comfortable meet their range at that time with a gentle stretch, and has established a Plan of Care. At that time, discharge them back to nursing for daily donning and doffing, but put on their therapy calendar to look at them again in 6-8 weeks to possibly pick them back up on therapy case load to readjust the splint farther toward normal alignment.  At that time, the patient’s tissue should be ready to begin the relengthening process.  If this is continued every few months throughout the year, at the end of 12 months the therapy staff will be amazed at the progress, and they have used the patient’s therapy cap wisely.  

Carrying out this process to correct lost range of motion “contractures” can, according to the joints/body parts affected, prevent Hospitalizations and ReHospitalizations, wounds, pain, feeding tubes, specialized beds and wheel chairs, dementia symptoms, falls... and even the need for institutionalization for 24 hour nursing care.  Correcting these deformities also helps to protect caregivers’ backs from injury during turning, repositioning and lifting patients, which saves medical facilities vast amounts of money on Worker’s Compensation injuries (and protects family members’ backs at home).  Win/win!

Therefore, the key is to differentiate patients between Orthopedic and Restorative (Neuro) and treat them accordingly.  Neuro patients who have lost range of motion – whether from tone, shortened tissue or a combination of both – require Flex Technology Splints™ to allow the body to go through its process to reach a relaxation through the Central Nervous System by gentle, flexible tugs on the tissue. 

Orthopedic patients require rigid splints after surgery or injury to hold a body part or joint in a specific plane to facilitate healing and function. Totally different types of patients that require totally different treatment measures and totally different splints.

A general understanding of the Central Nervous System and also the anatomy and physiology in the extremities is vital to providing appropriate treatment for these patients with conditions like: Cerebral Palsy; Traumatic Brain Injury, Acquired Brain Injury, Strokes and other brain conditions; Multiple Sclerosis; Parkinson’s; Spinal Cord Injury; Dementia and End Stage Alzheimer’s disease.  When patients suffer an injury or disease process of the Central Nervous System it is common for that person to begin to have inappropriate muscle contractions to a certain area of the body, in the entire body, or in the body below the level of a spinal cord injury, according to the area of injury and the extent of the injury.  These muscle contractions that are not relaxed because the controlling apparatus is not getting the message from higher neural centers to tell the muscle to relax is referred to as “tone.”

Unaddressed or inappropriately addressed tone leads to shortened tissue and any amount of tone or shortened tissue that prevents full range of motion is a “contracture” and a contracture is a deformity.  We talk about three types of Restorative, or Neuro contractures: Tone, shortened tissue, and a combination of both. 

Contracture deformities are an injury, and many times a preventable deformity.  Many patients with brain or spinal cord injuries develop tone the 3rd day after injury when they are still in the ICU.  If we fit them with a Flex Technology Splint™ and use nonaggressive stretching techniques then and continually relax the inappropriate muscle contractions (tone), we may see these patients go through the hospital stay with no deformity – through the rehab stay with no deformity – and perhaps walk home instead of leaving in a wheelchair and at times even to a long term care facility.   At the very least they will have less far deformity.

Rigid, orthopedic splints were never designed for neuro patients.  They were available and at some point it was realized that neuro patients needed splints, so the available ones were used on them.  If we watch the effects on patients using rigid splints versus when a Flex Technology Splint™ is used, the difference is remarkable.  Rigid splints and aggressive stretching tends to initiate tone in neuro patients, where the Flex splints will typically relax tone in about 15 minutes as they provide a gentle, flexible tug on the Golgi Tendon Apparatus. 

A highly respected Kentucky Physical Medicine and Rehab Physician, Kenneth Mook wrote:  “I have found that a static, rigid splint is not effective in controlling spasticity because it provides a persistence of a spastic event by not allowing the muscle to shorten. A splint that has static properties with some dynamic “give” during a spastic event allows the muscle to shorten, thereby the spastic event regresses, and yet the splint maintains the proper positioning of the joint.   

Most RMI products can be found online at our Neuroflex Store. 

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